Unfortunately, a quality improvement program won't work just because you say it should. Here's how to get the staff to buy in.

When considering quality as a business objective in long-term care, the term itself may have many meanings to different people. For instance, Phil Crosby, noted consultant in quality management, has defined quality as "conformance to customer requirements." On the other hand, Larry Miller, President of the Miller Consulting Group in Atlanta, Georgia, broadens the term to include such meanings as:

* Doing it right the first time

* Anticipating, conforming to, and exceeding |resident~ requirements

* Continuous improvement in product and process

* Speed

* Cost competitiveness

Many of today's residents and their families place great value on convenience, accessibility, efficiency and cost-effectiveness, all of which are encompassed within the quality concept. Further, the pursuit of quality involves a commitment to enhancing communications between departments, as well as with residents and vendors.

Working environment, policies, procedures, but most importantly, the organization's people will be key factors in developing a quality-oriented staff "culture." Miller notes, "The element of competition that does not flow easily from facility to facility, the scarce element in |health care~ today, is human competence and commitment. Examine any competition, one organization rising while another falls, and you will see that the key factor is the human spirit and skill."

Developing The "Culture"

Patience, discipline, persistence and creativity will be necessary to achieve such a culture. This comprehensive process must include the following critical factors:

Senior Management-Driven

As the leadership of the organization, the administrator's and senior management's style and vision are often the catalysts for action (or lack of it). A strategy for quality and a clear vision of where the organization wants to go must be defined and communicated by senior management to all employees. Senior management will be the primary driving force to encourage staff to actively engage in detecting quality shortfalls, recommending solutions and initiating improvements.

As an example of this principle in action, Judith Neblock, Corporate Quality Assurance Coordinator for International Health Care Management in Michigan, notes that when her company was formed eight years ago, senior management decided at the very beginning to establish a comprehensive QA program. A similar attitude is expressed by Sandra Hugg, Administrator at Morton Plant Rehabilitation and Nursing Center in Clearwater, Florida, who says, "I feel very strongly that if you don't have total support and total participation from the top, it won't work. It is almost like you live and breathe improvement, and you must show it every day in all of your actions."

Following senior management's commitment, a commitment for quality must then come from all levels of supervision. By supervisors serving as role models and being held accountable for maintaining high standards of excellence, a clear message will be sent to every employee that the facility is serious about quality and exceeding customer expectations.

For instance, every executive director and department head at each of International Health Care Management's 17 nursing facilities is a member of a QA committee. According to Neblock, each committee functions as a focal point for all QA efforts and issues that may arise within the local facility. Although facility administrators are the primary participants on the QA committees, she states that facility staff are also invited to become involved in various committee functions and tasks. "By rotating employee involvement in the process," she adds, "the company strives to increase employee participation, which will ultimately enhance resident service."

Expanding The Culture

A quality-oriented culture fosters employee buy-in, ownership and pride in the organization. If employees are to buy into the quality process, they will first want to know "what's in it for them." What will be their role in the quality process, and how will they benefit as a result of their contributions to progress? The answer is that the organization as a whole will benefit. In theory, improvements in quality automatically lead to improvements in productivity and customer satisfaction, thus enhancing the bottom line.

On a more personal level, though, employees will want to know how this process will enhance their careers. Management should take the time to establish this incentive. Basing performance evaluations, in part, on the employee's involvement, commitment and contribution to the quality process will reinforce the quality culture.

With this sort of commitment by management, Judy Neblock observes, "Employees gain a sense of control over their job by becoming less hesitant and more willing to speak up about areas in need of improvement. They know that action will be taken and that, ultimately, not only will the quality of service improve, but also the quality of their own working environment will be enhanced."

Forming A Quality Council

The concept of a Quality Council was originally introduced by J.M. Juran, a leading authority in Total Quality Management (TQM). In order to obtain the best representation of the organization, the Quality Council should be comprised of 3 to 5 volunteer members from various functions and levels throughout the facility. With the complete support of the Administrator and senior management, the Quality Council's role would include coordinating, launching and institutionalizing the quality improvement process within the organization.

As a first step, the Council would develop and publish a statement explaining the Council's role, including the Administrator's goals and the approach to the quality process. According to various sources in the field of quality management, the Council's responsibilities would include such functions as the following:

* To identify, recommend and monitor a communication system appropriate for the timely and accurate reporting of progress and activities relating to quality.

* To identify, recommend and establish various reward systems which support self-directed work teams (or "Partnerships For Quality"), continuous skill development, successful quality improvements, and individuals who contribute to quality improvement.

* Establish criteria for a quality assurance process.

* Establish, maintain and update a Quality Standards Manual which will contain documented standards and requirements for various systems, procedures, and services to help ensure consistency. This manual should be updated regularly by the primary Quality Council with assistance from employee participants, senior management, and department heads.

* Develop and perform audits of the organization's processes and services for to identify areas for improvement.

* Research and recommend training to assist staff in obtaining the necessary skills and tools.

The quality improvement teams might be called Partnerships for Quality; these are formed internally between departmental staff and externally with residents, family members, vendors and suppliers. While the Quality Council provides guidance and support, each Partnership for Quality team would determine the root cause for quality shortfalls, develop solutions and implement change. For these self-directed teams to succeed in their missions, training and education in quality improvement, problem solving and process leadership must exist.

Partnerships For Quality can also be defined as "Quality Circles." Karl Albrecht and Ron Zemke in their book, Service America: Doing Business In The New Economy, describe Quality Circles as, "a group of working level people who meet on a regular basis to find better ways to do their work." The authors add that in many cases a typical quality circle is an intact work group.

International Health Care Management's quality process has created several unique culture characteristics which Judy Neblock feels are important for the organization's success. First, she describes a "team-oriented approach" to problem solving which is geared toward long-term solutions rather than "quick-fix" attempts. Second, the company's encouragement of employee involvement in the QA process has enhanced the staff's commitment to the early identification and resolution of quality shortfalls. And third, management stresses an increased level of staff awareness, responsibility and accountability for quality of service through the support of education and the elimination of fear.

The goal of International's program is to maintain "hands-on" involvement by every employee in all 17 nursing facilities throughout the state. "Our company feels that when employees delivering the care get involved and take the process seriously, they can really make a difference," Neblock stresses. "Any QA process works only as well as the level of commitment and dedication given to it."

A Progressive Process

The quality of service which residents ultimately receive is actually the outcome of specific work processes performed by many different staffers. The old saying, "if it ain't broke, don't fix it," may not necessarily hold true for today's continuous quality improvement effort.

In order to meet the challenge of enhancing quality of service, managers must first assess how to improve the way things are done on an ongoing basis. For instance, Neblock explains that International's QA process utilizes an eight-step rotating approach for continuous quality improvement. This approach is used by each of the QA committees during their monthly meetings. The steps are outlined as follows:

International's use of a "quality monitor" allows each of the 17 facilities to assess individual adherence to performance standards in specific areas. For instance, areas measured by the monitor may include:

To illustrate the QA process, Marty Detloff, Director of Nursing at International's Nightingale Nursing Center in Warren, Michigan, recounts how one particular problem affecting quality of care was resolved using the eight-step process:

Upon review of the established standards (Step One) and following completion of the nursing monitor (Step Two), the rehabilitation department recognized that not enough attention was directed to contractures, or the care and treatment of frozen or stiff joints (Step Three). During the following monthly QA committee meeting, participants identified and prioritized the causes of the problem (Step Four). In this case, the two primary causes were a general lacking of attention and the need for new appropriate, adaptive equipment. The committee then prepared a written "Issue Log" which documented: 1) the nature of the problem; 2) primary causes; 3) resolutions; 4) the action plan; 5) individual responsibility; and 6) task time-frames (Step Five). At a later date, and specified by the action plan, the QA committee reconvened to review progress on procedural changes and the acquisition of the new equipment (Steps Six and Seven). Subsequently, International's nursing monitor was updated to reflect the new standards established for addressing contractures (Step Eight).

Elizabeth Oleskie, Social Service Director and QA Coordinator for International's Cambridge East Nursing Center in Madison Heights, Michigan, says that her facility finds the monitor to be a useful tool for inservice training. Past training sessions have focused on such procedures and practices as infection control, maintenance, laundry services and patient care. Recently, the facility also incorporated the monitor into its new employee orientations. New employees are therefore able to gain a higher level of understanding of the functions and responsibilities of other departments.

Karen Soleau, Executive Director of International's Frenchtown Nursing Care Center in Monroe, Michigan notes, "Our QA monitor actually forces us to recognize developing problems before they become too severe." Annie Weyher, QA Coordinator for the Monroe facility agrees. Weyher says that although she is responsible for distributing and analyzing the facility's monitors, it is the QA Committee which actually sees to it that problems are resolved. "As a team," Soleau adds, "the committee will determine how, when, and by whom such issues as improving sterile techniques or increasing resident use of the cafeterias will be addressed.

"The major benefits to our facility," Weyher notes, "is that communication between departments has been greatly enhanced as a result of the QA Committees. We have created a true team-oriented culture."

Investing in Quality

Improved quality of care is actually an investment. It is an investment in a better working environment, a new competitive edge, an enhanced bottom line, and meeting facility goals. This is an ongoing process -- there will always be room to improve. Developing and sustaining a successful quality assurance process requires total dedication, patience, skill, and involvement from all employees, as well as ongoing objective monitoring and a recognition system.

A quality assurance process that has no management buy-in and no mission, is not well-planned and executed, and does not invoke employee commitment, is surely doomed to fail.

Jeff L. Lefkovich, a consultant based in Windsor, CT, has developed quality improvement programs for many health-related corporations.